Background The cost of medicines is a significant barrier to improving access to medicines for Aboriginal and Torres Strait Islander people. Despite two to three times higher levels of illness, PBS expenditure for Aboriginal and Torres Strait Islander people is about half that of the non-Indigenous average.1 The Australian Government introduced the CTG PBS Co-Payment Measure in July 2010 to reduce or remove the patient co-payment for PBS medicines for eligible Aboriginal and Torres Strait Islander patients living with, or at risk of chronic disease. The measure aims to reduce the cost of PBS medicines for Indigenous Australians and assist in the prevention and management of chronic disease in the Primary Health Care setting. The PBS Measure is one of 14 measures in the Closing the Gap – Tackling Indigenous Chronic Disease Package. The CTG Co-payment Measure

Patients access more affordable PBS medicines by attending a registered general practice that participates in the Indigenous Health Incentive (IHI) under the Practice Incentives Program (PIP) or a registered non-remote (urban or rural) Indigenous Health Service.2 After checking a patient’s eligibility, general practitioners working at Aboriginal Health Services and at mainstream general practices that participating in the IHI will register the patient in the measure. Once a patient is registered, prescribers use their software to annotate their prescription to indicate that it is to be dispensed with co-payment relief. Prescribers can manually annotate prescriptions by writing the letters ‘CTG’ and signing next to the annotation. Upon presenting a correctly annotated prescription to a pharmacy for dispensing, eligible patients who would normally pay the full PBS co-payment will pay the concessional rate. Those who would normally pay the concessional price will receive their PBS medicines without the requirement to pay a PBS co-payment. However, premiums for a small number of medicines will still need to be paid by the patient.1 Prescriptions for all of an eligible patient’s PBS medicines are covered under the measure whether or not the medicines are being used to treat chronic or acute medical conditions. Hospitals are excluded from participating in the PBS Co-Payment Measure.
1 Department of Health and Ageing: Subsidising PBS Medicine Co-payments – Closing the gap, tackling Indigenous chronic disease http://www.health.gov.au/internet/ctg/publishing.nsf/content/subsidising-pbs-medicine-co-payments/$file/DHA6136%20B1%20Factsheet.pdf
2 Department of Human Services: Closing the Gap—PBS Co-payment Measure http://www.medicareaustralia.gov.au/provider/pbs/pharmacists/closing-the-gap.jsp
National Secretariat Level 2, 15 National Circuit, Barton, ACT 2600 Australia PO Box 7036, Canberra Business Centre, ACT 2610 Australia Telephone: + 61 2 6270 1888 · Facsimile: + 61 2 6270 1800 Email: [email protected] · Internet: www.guild.org.au Participation rates3 Cumulative PBS Co-payment Measure statistics for the period 1 July 2010 to 28 February 2013 show that:
194,640 patients are benefiting by accessing more affordable PBS medicines through the
In February 2013, 3,378 community pharmacies dispensed a ‘CTG’ annotated prescription
and over 99% of community pharmacies have participated in the measure since implementation;
4,459,982 'CTG' annotated prescriptions have been dispensed under the measure;
Uptake is highest in NSW with 40.98% of CTG prescriptions dispensed, followed by QLD
with 26.77%, WA with 10.97%, VIC with 8.57%, SA with 8.18%, TAS with 2.11%, NT with 1.56% and ACT with 0.84; and
the top 10 medicines dispensed under the Measure are: Atorvastatin, Metformin
hydrochloride, Salbutamol Sulphate, Perindopril, Codeine phosphate with paracetamol, Amoxycillin, Paracetamol, Cephalexin, Amoxycillin with clavulanic acid, and Esomeprazole magnesium Trihydrate.
Position

The Pharmacy Guild of Australia supports needs-based eligibility criteria for Aboriginal Peoples and Torres Strait Islanders living with, or at risk of, chronic disease who would experience setbacks in the prevention or ongoing management of chronic disease if the person did not take the prescribed medicine and are unlikely to adhere to their medicines regimen without assistance through the measure. There is evidence that the PBS Co-payment measure has improved access to medicines for Aboriginal and Torres Strait Islander people through reducing financial barriers resulting in improved health outcomes. However, some enhancements need to be made to further improve access to medicines by Aboriginal and Torres Strait Islander peoples through the CTG-PBS co-payment measure. Key issues that need addressing include:
1. CTG eligibility status and requirement of annotation on the prescription.
2. Interaction between programs and mobility of people living in remote areas.
3. Coverage of medicines under the CTG co-payment measure.
4. Improving Quality use of Medicines (QUM) support services
5. Promotion of the CTG co-payment measure.
The Pharmacy Guild of Australia ~ April 2013
1. CTG eligibility status and requirement of annotation on the prescription

When patients present with an unannotated CTG prescription at a pharmacy, they currently have to be sent back to the registered general practice or a registered non-remote Aboriginal Health Service (AHS) or the pharmacist has to contact the prescriber to clarify their intention causing a delay in access to medicines, even when the patient is known to the pharmacy to be an Aboriginal and/or Torres Strait Islander person with a chronic disease.
Pharmacists should be granted the ability to annotate prescriptions if patients are already known to be eligible for the CTG PBS Co-payment measure.
CTG eligibility status should be linked to the patient to address the portability issue so that the patient is eligible regardless of where they are and who the prescriber is.
Registration of an eligible patient should be linked electronically via the Medicare card to improve access and efficiency.
Linking the measure to the Medicare card would enable the pharmacist to call the Medicare helpline to check registration should a person present without their card. The PBS online system should also facilitate checking of CTG status.
Electronic registration linked to the patient would resolve the access issue when they are away from their home base and/or not attending their principal health care provider.
Linking CTG to the patient would overcome issues when medical practices are not registered under the Practice Incentives Program (PIP). Any prescriber should be able to annotate regardless of whether or not they are PIP registered.
Linking the measure to the Medicare card will improve patient’s privacy in community pharmacies. People who are eligible may be uncomfortable in self-identifying their eligibility if it is not raised by the GP or specialist.
Registration for CTG should be in real time and on-line rather than having to mail or fax the forms.
Alternatively, another system to consider is the system used by the Department of Veteran Affairs (DVA) where card holders have access to the range of pharmaceutical items available under the Repatriation Pharmaceutical Benefits Scheme (RPBS)4
2. Interaction between programs and mobility of people living in remote areas

The mobility of people living in remote areas needs to be considered along with their need to travel for specialist treatment and hospitalisation.
Linking eligibility to the Medicare card would enable residents living in remote locations who access medicines through the S100 Remote Aboriginal Health Services Program (S100 RAHSP) to automatically access CTG prescriptions when travelling in rural and urban
4 Department of Veteran Affairs: DVA Treatment Cards http://www.dva.gov.au/service_providers/treatment_cards/Pages/index.aspx
The Pharmacy Guild of Australia ~ April 2013
locations. This is currently not available and therefore limits an individual’s ability to travel and or have timely and affordable access to medicines in the event of travel.
Mechanisms are needed to enable the suite of PBS medicines programs to complement each other to better meet people’s needs with particular regard to travel between remote and urban areas, and between hospital and home, whilst still maintaining access to their PBS medicines.
Aboriginal Health Services in remote locations cannot currently provide both CTG prescriptions and medicines under the s100 RAHSP. These services should be able to provide services at their own discretion based on the needs of the patient whether under the S100 RAHSP or the CTG-PBS co-payment measure.
Hospitals should be able to issue people with discharge CTG scripts. Prescriptions from hospitals are excluded from this measure, even if the patient is already registered for the measure. This change would assist with the continuity of care for patients regardless of location or health care setting.
Integrating the CTG measure with existing initiatives such as Quality Use of Medicines Maximised for Aboriginal Peoples (QUMAX) may increase the impact of PBS co-payment’s measures.
3. Coverage of medicines under the CTG co-payment measure

The Criteria for the measure should cover the person not the illness. For example if an individual requires a medicine for something other than their listed chronic disease it should be covered to ensure the health issue is properly addressed and medicines compliance is not compromised.
The PBS listing for Aboriginal and Torres Strait Islander people needs to be expanded to better meet their health needs. There is a need to include commonly used medicines under the CTG measure, for example, vitamin D and Iron supplements. Inclusion of section 100 Highly Specialised Drugs should also be considered as it will improve access for a range of medicines including Clozapine.
4. Improving Quality use of Medicines (QUM) support services

Dose Administration Aids (DAAs) are designed to support at-risk patients (and/or their carers) in the community to better manage their medicine, with the objective of improving adherence and avoiding medicine misadventure and associated hospitalisation. There would be significant benefits to the patients and their families if DAA services were funded as part of the CTG Co-payment measure along the lines of the Department of Veterans’ Affairs (DVA)’s DAA funding model. The DVA service builds on their Quality Use of Medicines programs which include the Veterans’ Medicines Advice and Therapeutics Education Services and aims to assist the veteran community to get the most out of their medicines and to reduce medicine mismanagement. Ongoing coordinated care is provided by the GP and pharmacist.
The Pharmacy Guild of Australia ~ April 2013
Additional pictograms on medicines labels would improve health literacy along with other QUM education provided by health care providers5.
The development of drug information sheets in plain English for the most commonly prescribed medicines would complement the use of pictograms and increase impact of the CTG measure. This can be achieved by modifying existing consumer medicines information (CMI).
5. Promotion of the CTG co-payment measure

Information on how medicines are dispensed in different situations for Aboriginal and Torres Strait Islander peoples should be readily available to both patients and health professionals.
This consolidated information would assist patients in understanding and handling expectation as they move between different health settings.
5 Dowse R and Ehlers M (2005) ‘Medicine labels incorporating pictograms: do they influence understanding and adherence? Faculty of Pharmacy’,in Patient Education and Counseling, Jul 2005, vol. 58, no. 1, p. 63-70.
The Pharmacy Guild of Australia ~ April 2013